Provider Demographics
NPI:1396331005
Name:ALI, CHARISSE LILLIAN
Entity type:Individual
Prefix:
First Name:CHARISSE
Middle Name:LILLIAN
Last Name:ALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44005-0548
Mailing Address - Country:US
Mailing Address - Phone:440-319-2078
Mailing Address - Fax:440-998-5820
Practice Address - Street 1:1440 W PROSPECT RD
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6668
Practice Address - Country:US
Practice Address - Phone:440-319-2078
Practice Address - Fax:440-998-5820
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities